202 Industrial Blvd Ste 503, Sugar Land, TX 77478-2702

INTAKE FORM

INSURANCE ACCEPTED:

We accept Medicare & Medicaid. 

We accept Commercial/Private Insurance PPO's: eg. Aetna, Blue Cross, Blue Shield, Cigna, TriCare, United Healthcare, Sutter, etc.

What does ACCEPT mean? Say our charge for a service is $250.00. If we accept your insurance, then if your insurance only ALLOWS $100.00, we write off $150.00. If your insurance only PAYS $80.00, then the balance of $20 is owed by you. This balance includes your copay. However, the Plan you choose may have a DEDUCTIBLE that has to be met for the year, in which case, you would owe $100 until your deductible is met.

ACKNOWLEDGMENT OF ASSIGNMENT OF BENEFITS

AND FINANCIAL RESPONSIBILITY, and

RELEASE OF INFORMATION

I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, private insurance and other health plans, to IMMUHEALTHCARE, PLLC. The assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize IMMUHEALTHCARE, PLLC to use, to disclose, and to release any of my personal and healthcare information to secure payment. I authorize IMMUHEALTHCARE, PLLC to release my medical information to any physicians and healthcare providers as well as adjustors, case managers, vocational counselors, and pharmacists. I further authorize any physicians and healthcare providers to release my medical, laboratory, x-ray and diagnostic, pharmaceutical, and psychiatric records to IMMUHEALTHCARE, PLLC.

I acknowledge that I have been informed of my rights under the Health Information Protection and Portability Act (HIPAA), I understand that I may request copies of this information and rights any time.

IMMUHEALTHCARE, PLLC

ARBITRATION AGREEMENT

ARTICLE 1

It is understood that any dispute as to medical malpractice, that is, as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Texas law, and not by a lawsuit or resort to court process except as Texas law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

 

ARTICLE 2

a. Parties ToThe Agreement.  The term “Provider” as used in this Agreement includes IMMUHEALTHCARE, PLLC., and any of their employed or contracted doctors, nurse practitioners, physician assistants, chiropractors, acupuncturists or other healthcare providers and his or her professional corporation or partnership, and any employees, agents, successors-in-interest, heirs, and assigns of the foregoing individuals or entities. The Provider while not signing this Agreement is understood to agree to this Agreement on behalf of all the foregoing individuals and entities, and intends to bind each of them to arbitration to the full extent permitted by law.

The term “Patient” as used in this Agreement includes the undersigned individual, his or her spouse, children (whether born or unborn), and theirs, assigns, or personal representatives.  The individual signing this Agreement signs it on behalf of the foregoing persons, and intends to bind each of them to arbitration to the full extent permitted by law.  Submission to arbitration is a term of being a patient with Provider, and that commencing care constitutes acceptance and binds the Parties. 

b. Treatment Covered. Patient understands and agrees that any dispute of the sort described in Article 1 between Provider and Patient will be subject to compulsory, binding arbitration.

c. Other Providers (If Applicable).  Patient understands that he or she may at times receive treatment from one or more health care providers who take call for, render medical services by arrangement with, or otherwise substitute for the undersigned Provider.  It is understood and agreed that any dispute of the sort described in Article1 between Patient and such healthcare providers will also be subject to compulsory, binding arbitration.

d. Coverage of Prenatal Claims (lf Applicable}.  Patient understands and agrees that, if Provider treats her during pregnancy, any dispute of the sort described in Article1 as to medical treatment rendered to or affecting the unborn child will be subject to compulsory, binding arbitration.

 

ARTICLE 3

a. Informal Resolution of Disputes.  In the event Patient feels that an issue has arisen in connection with the medical care rendered by Provider, Patient will promptly notify Provider so that the parties may have an opportunity to resolve the matter informally.

b. Method of Initiating Arbitration.  If the issue cannot be resolved informally, Patient may initiate arbitration by sending a written demand to the Provider briefly describing the nature of his or her claim. Patient and Provider shall each designate an arbitrator to act as their respective party arbitrators. If more than two parties participate in the arbitration, parties aligned with Patient shall select one party arbitrator, and parties aligned with Provider shall select the other party arbitrator.  The two party arbitrators shall select a third person to serve as a neutral arbitrator, and the decision of the three arbitrators shall be final and binding upon the parties.

c. Interpretation of Agreement. If any part of this Agreement is held unenforceable, it shall be severed and shall not affect the enforceability of the remainder.  This Agreement supersedes and replaces any previous arbitration agreement between Provider and Patient and applies to all care previously rendered by Provider to Patient.

ARTICLE 4

a. Rescission. Once signed, this Agreement governs all subsequent medical services rendered by Provider to Patient until or unless rescinded by written notice within 30 days of signature.  Written notice may be given by a guardian or conservator of Patient if Patient is incapacitated or a minor.

NOTICE; BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.   SEE ARTICLE 1 0F THIS CONTRACT.

IMMUHEALTHCARE, PLLC

HIPAA Acknowledgement of Privacy Practices

My signature confirms that I have been informed of the right to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1966 (HIPAA).  I understand that this information can and will be used to:

• Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly,
• Obtain payment from third-party payers for my health care services.
• Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of the medical group’s Notice of Privacy Practices containing a more complete description of the uses and disclosure of my protected health information.  I have been given the right to review and receive a copy of such Notice of Privacy Practices.  I understand that the medical group has the right to change the Notice of Privacy Practices and I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.   

I understand that I may request in writing that you restrict how much private information is used or disclosed to carry out treatment, payment or health care operation, and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

CONTROLLED - SCHEDULED DRUG CONSENT & AGREEMENT

IMMUHEALTHCARE, PLLC is a Multi-Specialty Medical Group that specializes in Pain Management and Addiction Care, as well as Men’s Health, Women’s Health, and Medical Weight Management.

For any Scheduled Drugs which are defined as Controlled Drugs by the Drug Enforcement Agency (see Attachment A, which is part of the Agreement, below which outlines the Schedule), there are strict rules regarding their prescription, given the potential for dependency, addiction, abuse and misuse.  As a patient of IMMUHEALTHCARE, PLLC you understand the aforementioned and accept such risks, with the goals of improving safety and function.  To lessen these side-effects and complications, you consent and agree to the following:

1. You are personally responsible for my medication use and storage.
2. Any medications prescribed will not be refilled over the telephone, even if lost.  Any adjustments or refills will be made only in an office visit, never over the phone.
3. Narcotic medications can be prescribed up to a daily limit, at which point, the need may arise for referral to our Addiction Specialist.
4. You will use caution driving a car or using other hazardous machinery.  Abstain for several days when starting a new drug or after an increase in dose.
5. You acknowledge that you are not using any street drugs or alcohol, as the combination can result in significant impairment, accidents, and death.
6. You acknowledge that you have not been suicidal now or in the past.
7. If #5 or #6 applies, then you will schedule an appointment to notify the provider.
8. You agree that you will not seek medication prescriptions from any other physician office other than IMMUHEALTHCARE, PLLC.
9. You will use only one pharmacy for your medications.
10. You agree not to give or sell your medications to anyone.
11. You consent to drug screening via urine, saliva, hair, breath or blood.
12. You agree to waive any applicable privilege or right of privacy of confidentiality with respect to the prescribing of Pain and Scheduled medications.
13. You understand the side effects of sedation, itching, nausea, vomiting, difficulty urinating, constipation, and other side-effects are possible.  You further understand the risk of addiction and the probability of physical dependence exists and you consent to all these risks.
14. You understand that stopping narcotic medications may result in an abstinence syndrome.  You understand that in addition to the side effects listed above, a possibility of respiratory depression and even death exists from these medications.  If you feel sleepy, then you will not take these medications, even if your pain level or other problems are great.  You understand that if you take alcohol or illicit drugs or benzodiazepines with opiates you may die or suffer from brain damage.  You understand that if you do not take opiates as prescribed there is a risk of death.
15. If you do not wish to be prescribed controlled substances or wish to decrease the controlled-substance medications (Scheduled), then you will inform the physician that you wish to establish a program of alternative options of physical therapy, chiropractic, acupuncture, biofeedback, exercise, hormone treatment, injection therapy, ketamine therapy, and regenerative procedures such as stem cells and PRP.
16. If you feel you have a problem with addiction and substance abuse, then you will inform the physician that you wish to enroll in our Medication-Assisted Treatment  program which uses medications with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose.  MAT is primarily used for the treatment of addiction to opioids such as heroin and prescription pain relievers that contain opiates.

Attachment A:  Drug Schedules (from https://www.dea.gov/drug-scheduling )
 

Drugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug’s acceptable medical use and the drug’s abuse or dependency potential. The abuse rate is a determinate factor in the scheduling of the drug; for example, Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/or physical dependence. As the drug schedule changes-- Schedule II, Schedule III, etc., so does the abuse potential-- Schedule V drugs represents the least potential for abuse. A Listing of drugs and their schedule are located at Controlled Substance Act (CSA) Scheduling or CSA Scheduling by Alphabetical Order. These lists describes the basic or parent chemical and do not necessarily describe the salts, isomers and salts of isomers, esters, ethers and derivatives which may also be classified as controlled substances. These lists are intended as general references and are not comprehensive listings of all controlled substances.

 

Please note that a substance need not be listed as a controlled substance to be treated as a Schedule I substance for criminal prosecution. A controlled substance analogue is a substance which is intended for human consumption and is structurally or pharmacologically substantially similar to or is represented as being similar to a Schedule I or Schedule II substance and is not an approved medication in the United States. (See 21 U.S.C. §802(32)(A) for the definition of a controlled substance analogue and 21 U.S.C. §813 for the schedule.)  

                                                                                          

Schedule I

Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule I drugs are:

heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote

 

Schedule II

Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are:

Combination products with less than 15 milligrams of hydrocodone per dosage unit (Vicodin, Norco), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin

Schedule III

Schedule III drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Schedule III drugs abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. Some examples of Schedule III drugs are:

Products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone

 

Schedule IV

Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are:

Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol

 

Schedule V

Schedule V drugs, substances, or chemicals are defined as drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes. Some examples of Schedule V drugs are:

cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin

Appointment Cancellation Policy Agreement

IMMUHEALTHCARE, PLLC is committed to providing exceptional care. Unfortunately, when one patient cancels without giving enough notice, they prevent another patient from being seen. 

• Please call us at (925) 388-9800 by 2:00 p.m. on the day prior to your scheduled appointment to notify us of any changes or cancellations. 
• To cancel a Monday appointment, please call our office by 2:00 p.m. on Friday. 

If prior notification is not given, you will be charged $ 25 for the missed appointment. This is not covered by your insurance.

TELEMEDICINE CONSENT FORM

1. I hereby authorize IMMUHEALTHCARE, PLLC and www.immuhealthcare.com, to use the HIPAA-compliant telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical conditions.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements or patient difficulties can not be overcome.

4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.